Management of Acute Viral Hepatitis in Pediatric Patients
The primary approach to managing acute viral hepatitis in pediatric patients is supportive care, as most cases are self-limited and resolve without specific antiviral therapy. 1, 2
Initial Assessment and Monitoring
Laboratory evaluation should include:
- Complete blood count
- Liver function tests
- Hepatitis viral serologies
- Autoimmune markers
- Metabolic workup if indicated 1
Monitoring frequency:
- For children with elevated ALT: Monitor every 3 months for at least 6 months before considering antiviral treatment 1
- For confirmed chronic HBV with elevated ALT: Monitor ALT every 3 months for at least one year 1
- For HBeAg-negative patients: Measure ALT and HBV DNA every 4 months during the first year 1
Supportive Care Approach
- Bedrest for symptomatic patients
- High-calorie diet
- Adequate hydration
- Avoidance of hepatotoxic medications
- Complete abstinence from alcohol 2
Indications for Hospitalization
- Inability to maintain adequate oral intake due to severe nausea/vomiting
- Signs of dehydration requiring IV fluid resuscitation
- Any alteration in mental status suggesting evolving hepatic encephalopathy
- Coagulopathy or other signs of acute liver failure 2, 3
Special Considerations by Virus Type
Hepatitis A
- Self-limited disease that rarely requires specific antiviral therapy
- HAV vaccination is effective as post-exposure prophylaxis (comparable to immunoglobulin) 4
- Preschoolers are at higher risk for acute liver failure from HAV 4
Hepatitis B
- For acute HBV with severe presentation, lamivudine 100 mg/day may be beneficial, though evidence is limited 1, 2
- For chronic HBV, treatment decisions should follow specific algorithms:
- Treatment should only be considered if ALT remains elevated >1.5 times ULN for at least 6 months
- HBV DNA levels >2000 IU/ml
- Evidence of moderate to severe liver inflammation or fibrosis on biopsy 1
Hepatitis C
- Interferon-alpha therapy may be considered in acute hepatitis C to decrease chronicity risk 1
- For chronic HCV, combination therapy with pegylated interferon-alpha and ribavirin is effective, particularly for genotypes 2 and 3 1, 4
Management of Complications
Acute Liver Failure (occurs in 2-3% of cases)
- Requires immediate ICU admission
- Correction of coagulopathy
- Prevention and treatment of cerebral edema
- Management of renal dysfunction
- Early consideration for liver transplantation evaluation in severe cases 1, 3, 5
Common Pitfalls to Avoid
Premature antiviral treatment: Monitor children with elevated ALT for at least 6 months before considering antivirals to avoid treating those undergoing spontaneous HBeAg seroconversion 1
Treating children in immunotolerant phase: Children with normal/mildly elevated ALT and high viral load generally don't respond to interferon treatment and are poor candidates for nucleos(t)ide analogue therapy due to resistance risk 6, 1
Overuse of liver biopsy: Should be considered selectively, only when there is persistent ALT elevation after other causes have been excluded, or with family history of hepatocellular carcinoma 1
Failure to consider metabolic causes: In infants with acute liver failure, metabolic causes are more common than viral hepatitis 3
Delayed recognition of acute liver failure: Mortality is predominantly due to raised intracranial pressure, infections, and multi-organ failure that could be prevented with earlier intervention 3